The public health legacy of slavery
It has been 400 years since the first enslaved Africans arrived in the British colonies, yet the bodies of many Americans today are still marked by the effects of that horrible institution. Across the nation, African American adults have death rates from heart disease that are about one and a quarter times higher than white adults. African American women experience pregnancy-related deaths three to four times more than their white counterparts.
In Baltimore, these disparities are written on the map, with predominantly AfricanAmerican neighborhoods of the “Black butterfly” of East and West Baltimore showing lifespans 14 to 20 years shorter than those of largely white neighborhoods in the “White L” through the city’s center.
As primary care physicians working in a community health center across from the Latrobe Homes housing project, down the street from the jail complex, both of us go to work each week to confront the massive health inequities that are realities for African Americans.
These evils stem from the racial demarcation of urban neighborhoods from redlining policies, to our carceral systems and segregated institutions from Jim Crow, down the tracks of the Great Migration, past the failed promises of Reconstruction to the bodily harms and psychological trauma of plantation life. They can be traced to the Fells Point waterfront where Harriet Tubman hid slaves she helped escape, to the slave markets where Power Plant Live now entertains us and to the ships of the middle passage that killed more than 2 million enslaved Africans before they reached American shores.
Michelle Simmons, a mother and grandmother on the Johns Hopkins Center for Health Equity community advisory board, can feel the weight of this history. She grew up watching her parents struggle, having to choose between buying medicine or dinner. Her loved ones suffered from heart disease, emphysema, diabetes and cancer. Her mother died of a heart attack at 68, and her cousin died from diabetes at 62.
And, the histories of the public health often overlook the discoveries and contributions of enslaved African Americans — like the African slave Onesimus, who taught the principles of smallpox inoculation to Boston minister Cotton Mather in 1721. These histories often erase the role of public health institutions in exacerbating health inequities. Most infamously is the role of the United States Public Health Service in initiating and continuing the Tuskegee Study of Untreated Syphilis from 1932-1972, openly deceiving 600 black sharecroppers and their families in Alabama and sought to prevent treatment for syphilis over the next 40 years.
The histories we tell often omit the role of the health care system in perpetuating disparities, whether through delivering disparate care, regardless of income or insurance; inadequate support of the providers and systems that serve poor and minority communities; institutions’ discriminatory admissions and hiring practices; and the lack of inclusion of African Americans and other minorities in positions of leadership.
To move forward, we must confront these erasures. We are encouraged that across the country, disparities in years of life lost (a measure of premature death) between African Americans and whites decreased between 1990 and 2014, particularly in 20- to 64-year-old adults. While some of this reduction can be attributed to decreasing life expectancy among whites, some can be attributed to gains in life expectancy among African Americans.
We are also encouraged that under the Baltimore City Health Department B’More for Healthy Babies program, which provides local families with maternal and infant health services and support, the infant mortality rate per 1,000 live births in Baltimore City fell by 38% between 2009 and 2015. These efforts are slowly reducing the health divide that has characterized the African American experience since 1619.
For other meaningful interventions, city, state and federal policies need to be informed by a combination of historical analysis, community engagement, epidemiological research and implementation science, conceived and carried out with people whose daily lives reflect the legacy of historical and ongoing injustices. Health professionals and scholars cannot succeed without understanding the bitter roots of these health inequities. Injustice cannot be resolved without acknowledging and addressing its origins.
Dr. Lisa A. Cooper (lisa.cooper@jhmi.edu) is director of the Center for Health Equity at Johns Hopkins. Dr. Jeremy Greene (jgree115@ jhmi.edu) is a professor at Johns Hopkins.